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" On Sunday, the quasi-governmental organization, Quality Control of India, will introduce the accreditation process with the first stop of healthcare for most consumers: neighbourhood doctors. “Once the government passes the Clinical Establishments Act, it will be binding on all healthcare providers to seek accreditation,’’ said QCI secretary general Dr Giridhar Gyani.
How will Cliniq 21st help patients ? It will mean that a doctor with the brand has been attending continued medical education (CME) lectures, he or she will provide health checkups for his/her staff and the clinic will have minimum required emergency care equipment and the place will be fumigated once a week. “Once patients or their relatives see this Cliniq 21st board outside a doctor’s chamber or a clinic, they can expect a certain standard of treatment and infrastructure,” said Dr Ravi Wankhedkar of the Indian Medical Assocation’s state branch.

Cliniq 21st Must-Haves

Doctors must attend continued medical education of at least six credit hours every year (including 1/2 hour on emergency medication)
Clinics should be well lit and should have educative material
The staff should undergo health check-ups for communicable diseases at least once a year
All displays must be in two languages
Tariff cards should be published
A clinic must be fumigated once a week
Floor plan of the clinics should be available to patients and relatives
Doctors should maintain detailed records of their patients "

I am very excited that the government is making patient education compulsory for all clinics. This will help to empower patients with information and make medical therapy much more transparent and effective !

My daughter has not been well for the last 14 days. She’s been running a fever of about 100- 102 F – and this has been worrisome as a parent. As a doctor , I have learnt quite a bit about how healthcare works ( and does not). What have the lessons been ?

As with all illnesses, we hoped that the fever would be self – limited and would settle down on its own. We therefore treated it symptomatically, with masterly inactivity. My wife is now blaming herself for not doing anything for 4 days. However, I think this was the right decision. If we start treating every fever, then we’ll end up wasting time and money on overtesting and overtreatment. Fortunately, the body has quite a bit of its own wisdom and most problems are self-limited. Of course, we have no way of knowing in advance which fever is going to break on its own; and which one is going to be persistent, so there’s no point in beating up on yourself in hindsight. This again re-emphasises the role of the family as the primary medical care giver !

Since both my wife and I are doctors, we tend to be quite conservative and not over-react. However, when the fever persisted for more than 3 days then we did what every good patient should do – we consulted our family physician. We did the basic tests – and these all turned out to be normal, so we started empiric treatment with antimalarials and antibiotics. The fever broke, so we were all relieved – but then it came back again, so we needed to escalate.

This is when we realized how limited our diagnostic tools are ; and how difficult it is to make a diagnosis of such a common problem ! “ Fever panels “ ( a series of tests which labs provide) are fine if they are positive, but a negative test means nothing. Thus, she could have malaria, and we cannot rule this out just because the smear test is negative. This can be very frustrating – for both doctors and patients.

We took her to an internist, who did a marvelous job. He took a concise history; summarised the story of her fever in 3 lines; explained his plan of action; told my daughter what to do and what to expect; and reassured us. In about 15 min, he had completed his examination and assessment . His working diagnosis was made and we needed to run some more tests to confirm this. He selected an appropriate antibiotic and explained why he had chosen which one he did. He was an excellent clinician , and we were very happy with him ! ( However, even though he is an academic physician, I did notice that he did not have an electronic medical record. This means that he really has no way of critically analyzing the records of all the outpatients he has seen over the last 20 years of his practice , so that all his wisdom will remain clinical judgment, but will not be rigorously documented. )

As it turned out, coming to a diagnosis was surprisingly important. This label gives you a handle around which you can organize your thinking. Are we on the right track ? Are we missing anything ? How long will she take to get better ? What’s the prognosis ? Will this affect her studies? Even if the diagnosis may not be correct , it still provides a useful tangible end point around which medical care can be organized.

The internet was a bit of a disappointment because there was very little information on the management of fevers in India. This is a shame , because this is such a common problem , and there are so many worried patients looking for information. While there is a lot of information on typhoid fever and the antibiotics used for its treatment, not much of this is India-specific, so that one has to keep on reading between the lines . Why haven’t Indian doctors taken a more proactive role on educating their patients online ?

I do hope a clever young doctor will provide this very useful service. It could be a very simple guide for patients but would hold their hand and walk them through their next steps. When to worry; When not to; What tests to do and when; When to get a medical consultation; When to panic

Medicine still remains a combination of science and art – clever doctors use a mix of both to help their patients to get better !

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I seem to be seeing an epidemic of tuberculosis ( TB ) these days ! Practically all Indian patients who come to me have been treated with anti TB drugs ! Most gynecologists now routinely test the
endometrium ( uterine lining) for TB using a new generation of fancy ( and very expensive !) tests such as PCR ( polymerase chain reaction) . In the past, the only test available for making a diagnosis of TB was by growing the TB bacillus in the laboratory; or by finding tubercles on histological examination. However, both these methods are quite insensitive.

This is why PCR was introduced with great hope. This test amplifies a specific segment of DNA and labs believed that finding DNA sequences unique to the tubercle bacillus in the endometrial tissue would help to make a unequivocal diagnosis of TB infection. Unfortunately, this test has proven to be unreliable because it is too sensitive and can pick up even minute quantities of DNA, leading to many false positives. Because it is very expensive, it has not been validated in the fertile population, and in some labs, over 50% of the samples sent to them test positive for PCR for TB ! This obviously means the test is unreliable, but doctors continue doing it, without understanding its limitations and pitfalls – and patients are unnecessarily subjected to the trauma of 9 months of useless treatment !

Here's one simple reason why I feel the test is unreliable. When the tubercle bacillus reaches the genital tract ( from the lungs) , it first attacks the fallopian tubes and then later damages the endometrium . This means that whenever the endometrium is TB PCR positive, tissue from the fallopian tube should also be PCR positive. However, for many patients whose endometrium is positive, the fallopian tube is negative !

The other group of tests which is very popularly misused to make the diagnosis of TB are the blood tests which test for the presence of antiTB antibodies – both IgG and IgM. Firstly, remember that these tests are not picking up the presence of the TB bacillus – they are only testing for the presence of antibodies ( produced by the immune system to protect the body !) against the TB bacillus. As most Indians have been exposed to the TB bacillus, it is hardly surprising that many have the presence of antiTB antibodies, and often test positive. Doctors often believe that this is proof of TB infection, and promptly start treatment ! Similarly, the Mantoux skin test also tests merely for the presence of immunity against TB – and can be similarly misinterpreted.

In summary, the diagnosis of TB of the genital tract remains notoriously difficult to make. Most patients are misdiagnosed as having TB when in fact they don’t, and many are treated for no good rhyme or reason !

If your gynecologist diagnoses you as having genital TB based on these unreliable tests, then please do NOT start anti-TB medicines. Please insist on getting a second opinion from a physician, preferably once who is a TB specialist !

The truth is that no one really knows how to interpret these results - but no doctor will admit to this fact. What does a positive test mean ? Nothing ! I am sure if a controlled study is done , a lot of fertile women will also turn out to have positive tests for TB ! ( Actually, this would be an easy study to do ! Fertile women who are scheduled for a laparoscopic tubal ligation could have their endometrial biopsy done at the same time and this could be sent for testing for TB. It is my prediction that over 50% of these samples will turn out to be positive ! I'd love to be proven wrong !)

What's the result of all this testing ? A lot of unnecessary expense; and even worse , this leads to 9 months of unnecessary treatment with toxic drugs with unpleasant side effects. As a result of this waste of time, patients get fed up and frustrated. Sadly, most gynecologists are pretty clueless about what these results means - and it's much easier to "do something" ( prescribe antiTB medicines) rather than explain to the patients that nothing needs to be done !